Pediatrics Information Form

If you and your child(ren) are interested in participating in the University of Saskatchewan Clinical Learning Resource Centre's annual Pediatrics Assessment Module, please complete the information form below. This module teaches first year medical students how to interact with children aged 4-7 and 8-11 years. This involves asking the child and their parent/caregiver questions about the child’s current health and medical history, and completing a non-invasive head-to-toe physical assessment.

Please include the name and date of birth of all children who may participate in this program. If only one child will participate, please leave the additional fields empty.

Parent/Guardian's first & last name

Parent/Guardian's phone number

Child #1 first & last name

Child #1 date of birth

Child #2 first & last name (optional)

Child #2 date of birth (optional)

Child #3 first & last name (optional)

Child #3 date of birth (optional)

Are any of the children who will participate in this module currently under the care of a physician for an ongoing health issue?

Yes

Are you available to be called last-minute in the event we have a cancellation?

Yes

Do you or the children who will participate have any close family members or friends in the College of Medicine?

Yes